The Bureau of Epidemiology is available 24 hours a day, 7 days a week for consultation at our main number (SunCom 205-4401 or 850/245-4401) PLEASE NOTE: Consultation after 5 p.m. & on weekends is intended for emergencies.

Carina Blackmore, MS Vet. Med., PhD—Bureau of Epidemiology
Robin Oliveri, Arboviral Diseases Surveillance Coordinator—Bureau of Epidemiology

Surveillance results

Two cases of human arboviral encephalitis have been confirmed so far in Florida this year. A 73-year-old man from Madison County was diagnosed with WN virus encephalitis and a 9-year-old boy from Okaloosa County tested positive for Eastern Equine Encephalitis(EEE).

To date, 26 dead birds have tested positive for WN virus in North Florida, along with 7 horses and 1 chicken. By county, these are:

Okaloosa -- 1 bluejay

Eastern Equine Encephalomyelitis virus cases, confirmed or probable, per Florida DOH case definition, have been reported from the following counties:

Bay: 1 finch

Calhoun: 1 emu

Jackson: 1 horse

Jefferson: 1 horse

Holmes: 7 horses

Nassau: quail, 1 horse

Santa Rosa, 1 horse

Seminole 1 horse

Walton: 2 horses

Washington: 1 horse

Because of the arbovirus activity in North Florida, 28 counties extending from Santa Rosa to St Johns counties, have been put under medical alert.

The DOACS laboratory in Kissimmee has indicated to us that a significant number of the dead birds shipped to them are not of the quality needed for WN virus testing.

Therefore we want to take the opportunity to remind everyone to:

1. Only ship fresh birds (within 24h of death). Only ship Monday through Wednesday. Birds collected later in the week can be frozen and shipped the following Monday.
2. Make sure birds are shipped in a cooler, on ice.
3. For complete guidelines on handling and shipping birds for WN virus testing please go to our website:http://www.doh.state.fl.us/disease_ctrl/epi/htopics/arbo/10.htm

Carcasses that have started to decompose before pickup or during shipment to the laboratory are not suitable for testing.

There will be a conference call for County Health Directors addressing WN virus surveillance including OCA issues and resource needs immediately following the regular county health director’s conference call on Monday August 6.

Marc Traeger, MD, Epidemic Intelligence Officer—Bureau Of Epidemiology

Between March 1 and July 1, 2001 three University of North Florida students had onset of meningococcal illness, serogroup C. The cases were reported in a 19-year-old male, a 21-year-old male and a 21-year-old female. All cases were confirmed at the state laboratory in Jacksonville.

All case-patients were treated for their illness. Sixteen contacts to these case-patients received chemoprophylaxis for potential meningococcus exposure.

The detection of 3 primary cases of serogroup C meningococcal disease within a 3-month period constitutes an epidemic. The attack rate was then calculated, as per CDC guidelines (1). A vaccine campaign is indicated if the attack rate exceeds 10 cases per 100,000. The attack rate for this outbreak was 75 per 100,000 (2). The population at risk was then determined as students attending summer session courses between the ages of 17 and 25, with an estimated population of approximately 4,000.

A vaccine campaign was conducted by the Duval County Health Department and the University of North Florida student health services on the UNF campus July 31-August 1, 2001. The following tasks and events were completed between July 24 and August 1:

• Vaccination target group was defined.
• An intense planning effort took place, including discussions among members of Duval CHD, UNF, Putnam CHD, the CDC, the Bureau of Epidemiology and others with experience in meningococcal disease and vaccination campaigns.
• Staff and personnel were identified to conduct the campaign.
• The location and logistics of vaccine administration were determined. The physical facilities for the vaccine administration room were set up.
• A meningococcal disease hotline was established by Duval CHD.
• Press releases from Duval CHD and UNF were released 7/26/01, announcing the campaign.
• 4000 doses of vaccine were ordered; 2700 doses delivered to Duval CHD on 7/27/01 for the first day.
• Department of Health meningococcal disease website was updated 7/27/01.
• Vaccine protocols, preparation instructions and orders were signed and distributed; consent forms were completed.
• Educational materials were assembled.
• Instructions for all staff participating were established and written.
• A community education meeting on campus took place 7/30/01.
• A planning and discussion meeting on campus took place 7/30/01.
• An instruction in-service for nurses and nursing students took place 7/31/01.
• Vaccines were administered 7/31/01 and 8/1/01 beginning at 10:00 am, and continued through until 9:00 pm each day.

After 5 hours on the initial day, 960 vaccine doses had been administered, a rate of 192 per hour. 1300 more doses of vaccine were ordered to anticipate potential need at this rate. The additional doses of vaccine arrived on 8/1/01 in the afternoon. A total of 2501 vaccines were administered over both days (63% of the estimated target population); 1590 on 7/31/01 and 911 on 8/1/01. A total 274 vials of vaccine were actually used (representing 2740 doses; the additional doses attributed to variance in the amount of vaccine actually drawn up into syringes compared to that expected). The cost for the vials used amounts to $146,864; a discount of about 10% is expected from the manufacturer since the outbreak was verified by the CDC.

The attending physician noted very few vaccine reactions. Two students reported minor local reactions at the injection site. One student reported a rash, which was most likely an unrelated viral exanthum according to the attending physician.

There were no needle sticks, injuries or other adverse events related to the vaccine campaign.

Very few complaints were received about the process or the campaign. There were a few complaints verbalized about those excluded from the target population. Most comments were very complimentary, according to the attending physician.

References

Bureau of Facilities Programs: Eric Grimm, M.P.A., Ken Widergren, M.S.E.H., Ric Mathis, Leslie Harris, M.S.E.H., R.S.
Bureau of Onsite Sewage Treatment and Disposal: Gerald Briggs, Dale Holcomb
Bureau of Water Programs: Bart Bibler, P.E., Pepe Menendez, P.E., Ed Bettinger, R.S.
Monroe County CHD: Bobbi Sleighter, Bradley DeLashmutt
Bureau of Environmental Epidemiology: Roberta M. Hammond, Ph.D.

The environmental assessment of this camp was prompted as a result of the outbreak, which occurred mid-June and July (See the article by Dolly Katz in the Epi-Update for July 27). While the outbreak was determined to be person to person according to epidemiologic evidence, environmental conditions at the primitive campsite could contribute to future disease outbreaks, either person to person or food or waterborne. The Bureau of Facility Programs was the coordinating arm of this environmental assessment during the outbreak. The recreational camps are part of the Parks and Camps Program within the Bureau of Facility Programs. Staff from the bureau attended several telephone conferences with other bureaus of the Division of Environmental Health including the Bureau of Environmental Epidemiology, the Bureau of Water Programs, the Bureau of Onsite Sewage Treatment and Disposal and the Environmental Health Section of the Monroe CHD. Roberta Hammond, Bureau of Environmental Epidemiology, kept staff informed on the status of the outbreak investigation process and the current case count.

The primitive camp site, which was thought to be the locus of the outbreak, was an unpermitted camp that had been in operation since 1985. The base camp on Summerland Key was also not permitted. The camp is on a small 100 acre mangrove island, 10 acres of which were in use for camping. There are 12 camp sites each designed for 8 scouts plus one scout leader. In addition, an overall coordinator remains on the island for a total of 109 occupants. Scout troops are rotated on and off the island on a staggered basis. The island is never uninhabited during the main camping season, April-September. Division of Environmental Health and DOH legal counsel worked together on the issue of camp permitting and whether this site can be defined as a primitive campsite given the high volume and constant use with overnight stays. The camp is supported by the permanent camp on Summerland Key.

There is no running water or potable water source on the island. Water had been provided to the campers in 5 gallon jugs filled via hose at the Summerland Key base camp. This is an unapproved practice and was stopped immediately after the investigation. The 5 gallon jugs were transported to the island via boat and then poured into drink coolers with push buttons for use as drinking water, handwashing water and dishwater. The separate uses were not clearly marked on the drink coolers.

There is no approved and permitted sewage disposal on the island. Sewage disposal was provided in the form of 3 double-seated, unpermitted composting toilets that had not been properly maintained since installation. This particular type of composting toilet is not permitted for use in the State of Florida. There was a problem with filth and flies in and around each of the three toilet areas. Anecdotal reports stated that the toilet areas were so filthy that the scouts weren’t using them (and probably not washing their hands after not using them, either). The island has no provisions for the disposal of either gray or blackwater.

Handwashing facilities consisted of conventional drink coolers with push button faucets. This type of dispenser is not sufficient for handwashing use, as it provides multiple opportunities for contamination of the faucet area.

Food was kept in ice chests brought over for each 8 scout troop’s three-day segment. The ice was not replenished during the 3-day stay. Food consisted of potentially hazardous foods such as steak, hamburger, milk, sausage, sandwich meat, pre-mixed eggs, etc. Initial reports were that block ice was used for the ice chests, although photographs showed clear pictures of cubed ice in the chests. The ice was not evenly distributed in the chests providing opportunities for time/temperature abuse. The food was also not properly distributed, providing opportunities for cross-contamination. In addition, although tubs of water were provided for wash, rinse and sanitizing, these were not changed frequently and the water in them was filthy and stagnant. Since there is no permitted disposal of the dishwater, it is just poured on the ground after use.

The Division of Environmental Health provided the Monroe County Health Department with minimum measures of compliance before the island camp could reopen. The Monroe County Health Department closed the island to campers during the week of July 16-20, 2001. The Bureaus of Onsite Sewage, Water Programs, and Facility Programs all offered short-term and long-term requirements for the recreational camp to operate. The recommendations included food service, onsite sewage disposal, insect control, water supply, and the prevention of communicable disease. Legal staff in the General Counsel’s Office and from the Miami-Dade County Health Department provided legal guidance for the implementation of the plan developed by the bureaus. The Monroe CHD Environmental Health Section is continuing to work with the camp operators on the environmental recommendations (see below) to resolve these potentially hazardous situations and to prevent further occurrence of illness.

Note: These are short-term alternatives to allow the primitive portion of the camp to reopen for the rest of the season (August, 2001). The bullets indicate requirements, the numbers ranked alternatives (from most to less preferable). The camp has since reopened. The Monroe CHD will further discuss plans for the island campsite next season with the camp owners (see long term recommendations).

Public Health Education of Scouts and Leaders

• Personal hygiene
• Communicable disease
• Emphasize need for handwashing and how to properly wash hands
• Food safety and protection

• Though not required, strongly suggest: designate a separate sick bay area in both the main camp and on the island for campers who become ill

1. Commercially bottled, non-reuse, individual owner bottles (Other commercially bottled drinks (single use) ok) – up to 1 gal. containers
2. Self-filled, non-reuse, individual owner bottles filled on Summerland Key or elsewhere in appropriate sterile containers, using appropriate sources

Appropriate signage required:

• Sites designated as handwashing/not for drinking
• Signs: Wash Hands After Using the Toilet

1. Field handwashing stations with gravity-fed reservoirs, spigots (not push button), soap and paper towels, or
2. Commercially bottled water, soap and paper towels.
3. Water from base camp, filled in 5 gal. containers from an approved source, soap and paper towels. Water must be in dispensers with spigots (not push button dispensers).

• Single-use utensils
• No leftovers to be kept or consumed

1. Pre-packaged, ready-to-eat, non-perishable food (e.g. MREs (meals ready to eat), field rations, snack packs, etc.)
2. If potentially hazardous food is to be used (not the best idea):
• Potentially hazardous foods will be kept at 41 degrees Fahrenheit. A thermometer shall be provided for each cooler containing potentially hazardous foods.
• No leftovers to be kept or consumed.
• Screened food prep and cooking area.
• Increase the number of coolers and amount of ice used (also distribution of ice in coolers). Ice shall be replenished on a daily basis. Coolers should be properly drained.
• If cookware is washed on the island - (manual washing) it shall comply with Chapter 64E-11, F.A.C.
• A staff member assigned to the island shall have a food manager’s certification. This person shall train others on proper food handling techniques.

Sewage

• Service toilets if due (according to information, should be done every 2 years)
• Clean and sanitize on a daily basis
• Fans must be repaired
• Toilets must be enclosed in a screened enclosure
• Signs and education about putting down toilet seats
• Vent pipes must be screened
• Use fly bait or fly spray to eliminate the fly problem
• Install appropriate number of toilets per peak usage number of scouts (12 sites, 6 months per year, 8 scouts per site plus one counselor, plus one overall supervisor = 109)

Garbage

• Maintain and dispose of garbage appropriately (bring in/take out)

 

• Install well or desalinization unit (appropriate size/volume) to treat seawater

• Dual system
• Potable – fully treated water
• Other uses – not fully treated (minimum disinfection)

cisterns for non-drinking uses (however, no standards for cisterns in FL)

Notes: 1) Prevent cross-connections between the non-drinking and drinking parts of the water supply system.

2) System must be permitted by either the Department of Environmental Protection or the Monroe County Health Department depending on the number of people being served and amount of time those people are served.

• If potentially hazardous food continues to be used, the following items need to be addressed: Warewashing/sanitizing – single-use items are still recommended with daily delivery of food and return of leftovers and wares for washing at Summerland site. Coolers are not an option for long term. Either generators for proper cold and hot holding temperatures are needed, or do each meal catered from Summerland Key, military-style (i.e. meal brought in already cooked in hot holding equipment, ready-to-serve and leftovers, dishware removed until the next meal is brought over).

• Approved sewage disposal for the site (engineered system complying with all FL Keys requirements), appropriately maintained. Gray/blackwater disposal subject to current FL Keys standards.

• The camp is subject to any other DOH requirements.

Don Ward, Surveillance Section Administrator

The Annual Statewide Epidemiology Seminar, tentatively scheduled to be held on October 31 through November 2 in Clearwater, has been cancelled. Resources will not be available to support a face-to-face meeting of this size, which always requires a large travel commitment. In the place of the ASES, we are planning several satellite teleconferences in order to keep epidemiologists around the state abreast of current developments in the field. Look for announcements in the Epi-Update.

Don Ward, Surveillance Section Administrator

Linda Nelson, the DOH’s Chief Information Officer has informed us that Steve Alderson, the Bureau of Epidemiology’s web manager has received the "Charlotte Award" for web authoring excellence during the month of July. Mr. Alderson was awarded a certificate and custody of the Charlotte Award trophy. The citation on the certificate states:

"For web development excellence above and beyond the call of duty!

This award is presented in recognition of your diligence and support of the DOH internet site for helping to promote and protect the public’s health. Development of the Diseases and Conditions index used by all five health-related agencies and delivery of health alerts regarding the West Nile virus are outstanding contributions for which you are enthusiastically recognized."

Congratulations Steve! All of us in the Bureau recognize your excellent work every day and are pleased that others do as well.